IT Resources Request Notification

This form is to be completed for all individuals needing access to Company network/programs. Once entirely filled out, you must press “SUBMIT”.

Requestor Email
Request Type
IT Request Type Guide:

"Employee Update / Change" should be selected if an existing employee has changed positions within the same community (i.e. promotion and/or demotion).

"Employee or Third-Party Vision Only Access" should be selected if current employees and/or approved third-party vendors (i.e. Community Medical Directors, Community Pharmacists, Community Therapy) need access to internal specialty programs such as Vision. Be certain to use the IT Request Type of "Resignation / Termination" immediately when our business relationship ends with either.

User Type
User's Name

Certifications or titles that need to be displayed (i.e. DR, RN, LPN, RD, CDM)

Does this user have certifications or titles that need to be displayed next to their name (i.e. DR, RN, LPN, RD, CDM)

Does this user have certifications or titles that need to be displayed next to their name (i.e. DR, RN, LPN, RD, CDM)

Does this user have certifications or titles that need to be displayed next to their name (i.e. DR, RN, LPN, RD, CDM)

Does this user have certifications or titles that need to be displayed next to their name (i.e. DR, RN, LPN, RD, CDM)

* iCare is the iOS version of Vision, typically for community medical directors or doctors. If you answer yes, please be certain iCare is required as there is a monthly fee associated per license paid by the community.
Position Details
User Location
Notes
Resignation / Termination
New Hire
Network / Computer / E-mail Access
Phone
Employee Change
Third-Party Details

Examples include Medical Director, Nurse Practitioner, Pharmacist, Therapist, etc.

What Happens Next?

Once submitted, an email will be sent (using the user's email address provided above) to the user along with instructions on how to complete the Third Party Appropriate Use Signature Page. The email will come from helpdesk@maxwell-group.com Once the user completes, signs, and returns the form following the instructions, access will be provided directly to the user.

Please remember, if and when our business relationship ends with this individual, be certain to immediately complete the "Resignation / Termination" version of this form to prevent unauthorized access to our system(s).

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